Low Velocity Missiles Research Articles

Arrowhead Injury of Central Nervous System: Three Rare Cases from Rural India

AbstractA penetrating central nervous system (CNS) injury on account of an arrowhead is a rarity in the modern era. When managing such cases surgically, special care is taken to prevent injury to the neurovascular structures lying in the vicinity of the wound. Fired arrows are categorized as low-velocity missiles, but the size, shape and aerodynamic stability of the missile are also important factors in establishing the complexity of the wound. We present three such cases of penetrating injury of the CNS by fired arrows, two injuring the head and the third injuring the spinal cord. The arrowheads were successfully retrieved without any complications. Salient features to be taken care of while managing such patients have also been also discussed.

Air gun wound: bihemispheric penetrating brain injury in a paediatric patient.

Air guns are classified as low-velocity missiles and they usually considered safe and harmless. Despite that fact, air guns still can make serious or life-threatening injuries. Most of air gun injuries occur in paediatric population. A 2-year-old boy was shot in the forehead withan air gun accidentally. Skull radiography and non-contrast CT scan of the head were performed and showed penetrating bihemispheric brain injury from the left frontal to right occipital lobes at the level of the lateral ventricle with a metal-density foreign body at the right occipital. A projectile was successfully extracted via craniotomy, without complications. Air guns have the potential to cause fatal, life-threatening injury especially in children. Imaging is crucial for the evaluation of wound ballistics. Understanding about the mechanism of projectiles and wound ballistics is very helpful for radiologists to conceptualize these injuries when interpreting these cases. The role of radiology in ballistic wound cases is critical and important, both for clinical and forensic settings.

Treatment Protocol for High Velocity/High Energy Gunshot Injuries to the Face

Major causes of facial combat injuries include blasts, high-velocity/high-energy missiles, and low-velocity missiles. High-velocity bullets fired from assault rifles encompass special ballistic properties, creating a transient cavitation space with a small entrance wound and a much larger exit wound. There is no dispute regarding the fact that primary emergency treatment of ballistic injuries to the face commences in accordance with the current advanced trauma life support (ATLS) recommendations; the main areas in which disputes do exist concern the question of the timing, sequence, and modes of surgical treatment. The aim of the present study is to present the treatment outcome of high-velocity/high-energy gunshot injuries to the face, using a protocol based on the experience of a single level I trauma center. A group of 23 injured combat soldiers who sustained bullet and shrapnel injuries to the maxillofacial region during a 3-week regional military conflict were evaluated in this study. Nine patients met the inclusion criteria (high-velocity/high-energy injuries) and were included in the study. According to our protocol, upon arrival patients underwent endotracheal intubation and were hemodynamically stabilized in the shock-trauma unit and underwent total-body computed tomography with 3-D reconstruction of the head and neck and computed tomography angiography. All patients underwent maxillofacial surgery upon the day of arrival according to the protocol we present. In view of our treatment outcomes, results, and low complication rates, we conclude that strict adherence to a well-founded and structured treatment protocol based on clinical experience is mandatory in providing efficient, appropriate, and successful treatment to a relatively large group of patients who sustain various degrees of maxillofacial injuries during a short period of time.

Civilian Gunshot injuries to the Oro-facial region in Calabar, South-South Nigeria, 2002-2006

This article reviews 16 cases of civilian gunshot injuries of the oro-facial region seen at University of Calabar Teaching Hospital, Calabar over a 5-year period and highlights the rising trend in the occurrence of gun shot injuries to the orofacial region as experienced in the south-south region of Nigeria. Records of 16 patients with different types of gunshot injuries to the oro-facial region seen and treated at the University of Calabar Teaching Hospital, Calabar between 2002 and 2006 were reviewed. The focus was on the patient's age, gender, type of weapons used, the surrounding circumstances (accidental or intentional), the time of occurrence and management. Out of 16 patients seen, 14 (87.5%) were males and 2 (12.5%) were females, giving a male to female ratio of 7:1, with the age range from 18 to 50 years. Thirteen (81.3%) of the patients were injured by low velocity missile while 3 (18.7%) by high velocity missile. Violence was responsible for 14 cases (81.7%), and 2 cases (18.3%) was due to the accidental discharge. This study has shown an increasing occurrence of gunshot injuries to the oro-facial region in our environment with males more affected than females. With the changing political situation, social advancement and urbanization, there is a need to regulate the influx of deadly weapons in the country by the relevant agencies. Maxillofacial surgeons should also brace up to the new development as this poses a new kind of challenge to our knowledge of trauma management.

Gunshot Injuries In A North Eastern Nigerian Tertiary Hospital

Background: Worldwide gunshot injuries are causes of considerable burden to patients and the society. Such burdens are not limited to huge financial demands but may lead to outright victims' permanent disability or demise. Objective: To determine the incidence, causes, pattern and outcome of gunshot injury in patients presenting to a tertiary Nigerian hospital. Design: A five year retrospective study. Method: The analyzed data were retrieved from patients' registers in the wards and operating theatre and from case notes. Outcome: There were substantial morbidity and mortality despite the preponderance of low velocity missiles necessitating admission in 73.9% of patients. Intentional injuries occurred in 91 (76.5%) patients and were caused by armed robbery in 78 (65.5%) and by assault in 10 (8.4%) patients while 28 (23.5%) patients had accidental discharges. The lower limbs (45 patients; 37.8%), the upper limbs (21; 17.6%) and the abdomen (13; 10.9%) were the frequently involved sites while gluteal region (2; 1.7%) and perineum (1; 0.8%) were the least affected sites. Multiple-site injuries were seen in 11 (9.2%) patients. Duration of hospitalisation ranged from one to 183 days (mean: 29.9 days). Most of the admissions were a result of long bone fractures (32 patients; 26.9%), abdominal injuries (12; 10.1%) and major soft-tissue injuries (9; 7.6%). Long-bone fractures were also responsible for the longest hospital duration while patients admitted on account of long distances had the shortest stay. Wound infection was the most frequent noted complication and there was a mortality rate of 3.36%. Conclusion: A concerted effort at preventing local proliferation of firearm use and prevention of further regional and sub-regional influx of firearms from wars through sustainable peace initiatives and surveillance systems is imperative.

Missile Injuries of the Limbs: An Iraqi Perspective

Missiles include pistol or rifle bullets, shell fragments, land mines, and grenades. Medium- and high-velocity missiles produce damage by laceration and crushing, shock waves, and cavitational effects. Low-velocity missiles produce damage by laceration and crushing only. Land mine injuries cause damage by the primary blast effect, secondarily by fragments, and thirdly by the effect induced by whole-body propulsion and by burns. Severity of injuries should be graded according to the degree of soft-tissue damage, bone defect or comminution, and vascular or neural injury. Among other factors, successful management of these injuries requires prompt and vigorous resuscitation, careful wound inspection, aggressive exploration, liberal débridement, and prompt removal of fragments. In addition, in these circumstances, one must stay alert for overlooked injuries and be aware of associated psychological trauma.

A Case of a BB-gun Pellet Injury to the Ethmoid Sinus in a Child

Injuries caused by BB and pellet guns remain common among children. These guns fire low-velocity missiles that can cause considerable harm when fired at close range. Most injuries occur in adolescents as a result of accidental or careless shooting. Such injuries to head and neck sites are common, second only to injuries to the extremities. We report the case of a 10-year-old girl who was accidentally shot by a BB gun. The BB pierced the skin of her right cheek, traversed the right maxillary sinus walls, and lodged at the junction of the right ethmoid sinus and septum. Preoperative radiology combined with endoscopic surgery techniques and instrumentation allowed us to precisely locate and remove the steel ball from the paranasal sinus while the patient was under general anesthesia. We review the scope of maxillofacial injuries caused by BB and pellet guns, and we discuss their presentation, diagnosis, and management. Although these guns are easily bought and sold as toys, they are weapons capable of causing significant injury.

Low velocity gunshot injuries to the temporal bone.

To review the presentation, symptoms and management associated with low velocity gunshot injuries to the temporal bone. A retrospective analysis of 26 patients treated for low velocity gunshot injuries to the temporal bone. Initial presentation included otorrhoea (69 per cent), facial nerve injury (27 per cent), hearing loss (65 per cent), intracranial injuries (50 per cent), and cranial neuropathies (58 per cent). Nine patients (35 per cent) underwent angiography, which showed vascular injury in five of them. Four patients died. Low velocity gunshot injuries can be devastating and may result in functional sequelae. Low velocity missiles crush and lacerate surrounding structures, while high velocity missiles cause extensive wound cavity formation. Early aggressive management for intracranial, vascular and facial nerve injury can improve outcome.

Local response of concrete slabs to low velocity missile impact

A new model to predict the penetration and perforation of concrete slabs impacted by low velocity missiles, is presented. The two-stage model incorporates a first stage penetration algorithm into an infinite medium and a second stage of punching shear. The transition between stages is determined and the penetration time history as well as concrete plug shear resistance and shape are calculated. The present model predictions are compared with several common formulae as well as with test data and good agreement is obtained.

CT of a peripatetic intracranial foreign body

We report the CT appearances of a low-velocity missile that lodged within the brain and which subsequently migrated spontaneously back along the entry path. We review the literature of similar instances of migration and draw conclusions about the presurgical radiological management.

Management of Civilian Gunshot Injuries to the Hip

The orthopedic surgeon at a civilian trauma center is likely to encounter a gunshot injury to the hip. The nonmilitary literature regarding this injury gives few guidelines regarding an appropriate diagnostic evaluation or the indication for arthrotomy. We found that the best diagnostic test to detect joint penetration was hip aspiration followed by an arthrogram. Selected cases can be treated successfully with antibiotic therapy without an arthrotomy. These cases involve a low-velocity missile that passes through the joint, causes minimal bone disruption, and is free of bowel contaminants. If an arthrotomy is not performed, the physician must follow the patient with repeated physical examinations, complete blood counts, and a hip aspiration whenever infection is suspected. All transbdominal hip injuries require an immediate arthrotomy. In this series, bullets left in contact with joint fluid resulted in joint destruction or infection. Each patient with a displaced femoral neck fracture had a poor outcome with internal fixation. Hip arthroplasty or fusion should be considered as elective procedures for definitive management of these injuries.

Penetrating thoracic wounds caused by plastic bullets

Thoracic penetrating injuries caused by a new plastic bullet were studied to determine the nature of the wounds and the appropriate management. Twenty-six casualties from the Israeli-Palestinian conflict (Intifada) were included. The organs most commonly involved were lung (n = 21), bony chest wall (n = 9), heart (n = 3), and diaphragm. Bleeding was at least moderate in 20 patients, amounting in all patients to an average of 975 ml. Thoracotomy was required in 11 patients (42%) mainly because of cardiac injury (n = 3) and aortic or other arterial bleeding (n = 3). Simple oversewing of severed organs (n = 8) or ligation of bleeding vessels (n = 3) was satisfactory. Two patients died (7.7% mortality); one after major liver resection; the other was dead on arrival. We conclude that plastic bullets have a linear course unless displaced by the bony chest wall, when they tend to fragment and cause simple fractures. Fired from a presumed range of at least 70 m, plastic bullets behave like low-velocity missiles, and tissue destruction is minimal. Management should be similar to that of civilian thoracic penetrating trauma.

Tangential Low-velocity Missile Wound of the Head with Acute Subdural Hematoma: Case Report

Tangential missile wounds of the head without skull fracture are a known entity. Usually, references in the literature indicate that this type of injury results from a high-velocity missile impact. We present a case of a tangential missile head wound caused by a low-velocity missile. As the range of fire was short, the quantity of energy that might be released could be equated with that released by a high-velocity missile fired from a much longer range. This possibility should be brought to the attention of clinicians as an essential element in this pre-treatment clinical evaluation. We propose a pathomechanical explanation for the development of the clinical state.

Femoral Fractures Secondary to Low Velocity Missiles

The literature is replete with descriptions of the advantages of intramedullary nailing in the treatment of femoral fractures. However, little has been reported about the use of this method in femoral fractures resulting from gunshot wounds. Often, the amount of bony comminution and retained metal fragments have discouraged attempts at operative intervention. We reviewed our experience with 26 patients who had sustained low velocity gunshot fractures of the femur that were treated operatively with intramedullary fixation. After injury, the patients were stabilized in the emergency room and placed in balanced skeletal traction. They also received local wound care. When the patients recovered from associated injuries and the bullet wounds were healing, a delayed closed intramedullary nailing was performed. Nineteen patients were followed to union. Seventeen had fractures that united at an average of 4.5 months. One patient had a delayed union, and one had a nonunion. There were no deep wound infections and no cases of osteomyelitis. Range of motion was within 10 degree of the unaffected side in all but one patient, and there were neither rotatory nor angular deformities.

Reconstructive Surgery After Perforating Trauma of the Lower Urinary Tract

Whereas perforating injuries of the lower urinary tract with low-velocity missiles usually heal without sequelae, high-velocity missiles always cause extensive tissue sloughing and subsequent scar formation, which require difficult reconstructive surgery. As associated injuries of neighboring organs are the rule, an individual multidisciplinary approach is required. In 26 patients treated, urorectal fistulae had to be closed in 43% and the urethra was reconstructed in 62%; 37% required major orthopedic interventions. Rectourethral fistulae are best managed by the Mason transrectal technique. Shorter strictures of the urethra can be bridged by scar excision and end-to-end anastomosis and this was successfully performed to the bladder neck in 3 patients. Mine explosions affecting the perineum result in extensive destruction of the bulbar urethra, anus and rectum. Reconstruction must be staged into separation of urethra and rectum, repair of the anal sphincter, and urethroplasty. By covering defects with split-thickness skin meshgrafts, a shortage of skin is avoided. Impotence is managed with penile prostheses. Incontinence is usually due to associated neurogenic lesions and can in general be treated conservatively. In this series, all patients were freed of urostomies or colostomies and full rehabilitation was achieved in all with the exception of a tetraplegic patient. As documented by a mean of 2.8 operations and 37 days of hospitalization per patient, patience and time are essential prerequisites for success.

Management of civilian gunshot wounds in a Nigerian general hospital.

In a 3-year period (1981-1984), 52 male patients aged 10-60 years were treated for fresh gunshot wounds. The injuries varied from minor soft tissue injuries to major organ and tissue damage, and were all sustained by low-velocity missiles. Six of the patients (11.5%) died of their injuries or complications while 46 (88.46%) survived and were discharged after 1-15 weeks (a mean hospital time of 3 weeks). Some of the patients were treated before referral and for some there was a delay of more than 48 h before definitive specialist treatment. Mortality was related to the severity of wounding and the delay before treatment.

Reconstructive surgery after perforating trauma of the lower urinary tract

Whereas perforating injuries of the lower urinary tract with low-velocity missiles usually heal without sequelae, high-velocity missiles always cause extensive tissue sloughing and subsequent scar formation, which require difficult reconstructive surgery. As associated injuries of neighboring organs are the rule, an individual multidisciplinary approach is required. In 26 patients treated, urorectal fistulae had to be closed in 43% and the urethra was reconstructed in 62%; 37% required major orthopedic interventions. Rectourethral fistulae are best managed by the Mason transrectal technique. Shorter strictures of the urethra can be bridged by scar excision and end-to-end anastomosis and this was successfully performed to the bladder neck in 3 patients. Mine explosions affecting the perineum result in extensive destruction of the bulbar urethra, anus and rectum. Reconstruction must be staged into separation of urethra and rectum, repair of the anal sphincter, and urethroplasty. By covering defects with split-thickness skin meshgrafts, a shortage of skin is avoided. Impotence is managed with penile prostheses. Incontinence is usually due to associated neurogenic lesions and can in general be treated conservatively. In this series, all patients were freed of urostomies or colostomies and full rehabilitation was achieved in all with the exception of a tetraplegic patient. As documented by a mean of 2.8 operations and 37 days of hospitalization per patient, patience and time are essential prerequisites for success.

Late Ureteral Damages from Gunshot Wound by High and low Velocity Missiles

Late Ureteral Damages from Gunshot Wound by High and low Velocity Missiles

Angiographic aspects of traumatic intracranial aneurysms following war injuries.

Intracranial aneurysms following head injuries occur very rarely. Only 15 cases following injuries by missiles or shrapnel have been reported in the world literature. The angiographic findings in seven cases injured during the recent fighting in Lebanon, are described. The relatively high frequency of occurrence of these aneurysms in our cases might be explained by the fact that they were injured by low velocity missiles. A high velocity missile would disrupt an artery completely. It is also of interest that most of the aneurysms originated from arterial branches along the path of the foreign body, but not in contact with it. Unlike congenital aneurysms, they bore no relationship to arterial bifurcations and, unlike aneurysms following closed-head injuries, none involved the large basal arteries. None of them had a neck, and a mass effect due to bleeding was found in six of the cases.

Missile-induced vascular trauma

During seven and a half years of serious hostilities amidst the civilian population of Northern Ireland, a wide variety of vascular injuries inflicted by low and high velocity missiles and bomb explosions were observed. One hundred and thirteen patients, 96.5 per cent males of average age 26.8 years, sustained 191 vascular injuries and were treated at the Royal Victoria Hospital. Treatment commenced within one hour in 87 per cent of patients. Reduced limb ischaemia time, early bleeding control and vascular repair with restoration of flow within 6 hours of injury in 94.4 per cent of patients contributed to an excellent result in 85.5 per cent of survivors. Despite rapid admission, the mortality rate within 3 days of injury was 12.4 per cent, these patients sustaining trauma to major vessel trunks and vital organs. Associated nerve injuries (25 per cent) and skeletal injuries (30 per cent) were treated appropriately. A special group of 38 patients were ‘knee-capping’ victims and contributed to the majority of popliteal vessel trauma. A total of 14.9 per cent of primary arterial and 3 per cent of primary venous reconstructions failed due to thrombotic occlusion, but early postoperative revision was successful in every case. The overall amputation rate for lower limb injuries was 6.9 per cent; of these 5 cases, 4 had popliteal vessel injuries, in 2 of which infection (acute clostridial and chronic osteomyelitis) was partly responsible. Significant wound infection was otherwise absent. The pathophysiological aspects pertinent to the range of weaponry and methods of assault are presented. The operative and postoperative management and results are discussed in the light of documented military and civilian experience.